I am a 37 year old male in good health. I have Aortic Valve Replacement at Fairfax hospital by Dr. Edward Lefrak on January 23, 1996. I had a St. Jude Mechanical valve placed. I am Warfarin resistant. I take 23.5 mg of Coumadin per day to maintain an INR of between 2.5 and 3.5. I had to be hospitalized twice in the first 6 months post surgery. Once for a Basal Ganglion Infarction, from which I recovered completely and once simply to be placed on Heparin due to a low INR. I have been ok since then. I would like to get rid of this valve. Are there any other options availible to me? Have there been any advances in cloned valves? As a young, active person I am not sure an animal valve is the answer. I just feel as though I am literally a ticking bomb.

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: Dear Christopher,
Thank you for your question. If you are able to achieve and maintain an adequate INR on warfarin (coumadin) I would not think it worthwhile to change your valve. Some people will require higher dosages and yours is one of the higher ones I have seen. However, now that things have stabilized the risks of subsequent surgery may outweigh the benefits of being off anticoagulation. There is nothing in the near future with cloned valves and if you received a tissue valve it would most certainly need to be replaced several times. I suppose one option might be to start an injectable heparin called low molecular weight heparin. This type of heparin does not require blood monitoring but is costly and is not FDA approved for this indication.
Be sure that you are not doing anything that could be interacting with the coumadin. There are many drugs that interact with coumadin (see below). Common foods such as grapefruit juice, leafy green vegetables and many drugs can change coumadin levels. Smoking also changes drug levels. Also be sure to take the same brand of drug each time and always take the drug at the same time of day (usually 6pm).
The following is information on warfarin and it's drug interactions.
Coumadin (generic name Warfarin) is a anticoagulant (blood thinner) that is used for a variety of conditions. Common reasons for coumadin use are in atrial fibrillation to reduce the risk of stroke, in persons with clotting disorders, in persons with mechanical heart valves, and sometimes in people with severe heart failure. The usual dosage is somewhere between 1 and 15 mg a day. Potential side effects include bleeding, hair loss, nausea, vomiting, stomach cramps, diarrhea and leukopenia (low blood cell count). The half life (amount of time for half the drug to be cleared from the body is 42 hours but varies widely depending on the individual).
Many drugs interact with coumadin and may cause more anticoagulation effect (clofibrate, diazoxide, ethacrynic acid, nalidixic acid, phenylbutazone, salicylates, aspirin, sulfonamides, alcohol, allopurinol, amiodarone, cimetidind, phenytoin, erythromycin, gemfibrozil, propranolol, thyroid drugs) or decreased anticoagulation effect (smoking, estrogens, vitamin K, aluminum hydroxide - antiacids, cholestipol, spironolactone). See complete list below. The effects of coumadin must be carefully monitored by a blood test called an INR. Usually this is checked more often at the onset of taking the drug and less often once a steady state has been reached. Therapeutic INR is usually 2 to 3 depending on the condition being treated.
Pregnant women and those with a hypersensitivity to coumadin should not take this medication.
The medication should not be taken with food and any signs of bleeding should be reported to your doctor. Use a soft toothbrush, avoid hazardous activities, carry Medi-Alert ID identifying drug useage and notify your doctor if you have any dark brown urine or red or tarry black stools.
Known Drug interactions with Warfarin
Increased Effect :
Highly Probable
Alcohol (if concomitant liver disease)
Amiodarone
Cimetadine
Clofibrate
Cotrimoxazole
Erythromycin
Fluconazole
Isoniazid
Metronidazole
Miconazole
Omeprazole
Phenylbutazone
Piroxicam
Propafenone
Propanolol
Sulfinpyrazone
Probable
Acetaminophen (Tylenol)
Anabolic steroids
Aspirin
Chloral Hydrate
Ciprofloxacin
Dextropropoxyphene
Disulriam
Quinidine
Phenytoin (Dilantin)
Simvastatin
Tamoxifen
Tetracycline
Influenza vaccine
Possible
Disopyramide
5-Fluorouracil
Ifosphamide
Lovastatin
Metolazone
Nalidixic Acid
Norfloxacin
Ofloxacin
Topical salicylates
Sulindac
Tometin
Doubtful
Cefamandole
Cefazolin
Gemfibrozil
Heparin
Indomethacin
Sulfisoxazole
Decreased Effect

I hope you find this information useful. Information provided in the heart forum is for general purposes only. Only your physician can provide specific diagnoses and therapies. Please feel free to write back with additional questions.
If you would like to make an appointment at the Cleveland Clinic Heart Center, please call 1-800-CCF-CARE or inquire online by using the Heart Center website at www.ccf.org/heartcenter. The Heart Center website contains a directory of the cardiology staff that can be used to select the physician best suited to address your cardiac problem.

DEAR Christopher:
I found that taking coumadin on an empty stomach about 1 hour before meals helped me maintain my INR levels which slipped when I took it with food.
Nathan

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